Abstract
Over the last two decades, there have been tremendous medical and surgical advancements in the care provided to children with congenital and acquired heart disease. Technologic improvements in extracorporeal cardiac support continue to decrease mortality rates in this group of patients. Patients with complex congenital and acquired heart disease often present significant management challenges for the cardiac intensive care unit (CICU) provider. To understand and meet the demands of this patient population, cardiology, critical care, and anesthesiology practitioners have been tailoring their education and training to provide optimal care. Academic pediatric centers offer additional education and training in pediatric subspecialties in the fields of critical care, cardiology, and anesthesiology to prepare providers for careers as pediatric cardiac intensivists. Available guidelines for training in pediatric cardiology, pediatric critical care, and pediatric anesthesia separately exist, but there is no consensus on the specific training pathway, the duration of that training, or in the specifics of mentoring and recruitment for the next generation of CICU providers. These challenges, along with the gradual transition nationally to dedicated pediatric cardiac critical care units and intensivists, have intensified the discussion to standardize training. This chapter provides a historical background in the field of pediatric critical care, highlighting the critical skills and expertise required by CICU providers. The various training pathways available for cardiac intensive care practitioners are summarized, followed by a proposed curriculum and possible assessment strategies for those in training. Finally, information regarding board certification, mentoring, and recruitment for CICU providers is presented.
Key Words
pediatric cardiology, pediatric critical care, education, training, mentorship, recruitment
Over the last decade there has been a tremendous growth in the amount of medical and surgical advancements in the treatment of children and adults with congenital heart disease. Technologic improvements in extracorporeal cardiac support continue to decrease mortality rates in this group of patients. Nonetheless, patients with complex forms of congenital heart disease often present significant management challenges for the cardiac intensive care unit (CICU) provider. In an attempt to understand and meet the demands of this patient population, cardiology, critical care, and anesthesiology providers have been tailoring their education and training to make steady improvements in the care provided to this group of patients. Academic pediatric centers across the United States offer and provide additional time for education and training in pediatric subspecialties that encompass the fields of critical care, cardiology, and anesthesiology. Available guidelines for training in pediatric cardiology, pediatric critical care, and pediatric anesthesiology exist, but there is no consensus on the training pathway and duration or on the specifics of mentoring and recruitment for the next generation of CICU providers. These challenges, along with the continued transition nationally to dedicated pediatric cardiac critical care units and intensivists, have intensified the discussion to standardize the approach to pediatric cardiac intensivist training.
This chapter will provide historical background in the field of pediatric cardiac critical care, highlighting the development of the skills and expertise currently required to provide optimal care in the CICU. Description of current training pathways used by pediatric cardiac critical care providers will be reviewed. Introduction of a proposal for curriculum standardization and best practices to assess trainees in the field, focusing on the current graduate medical education paradigms of milestones and entrustable professional activities (EPAs), will be provided. A description for board certification, mentorship, and recruitment for CICU providers will also be presented.
History of the Cardiac Intensive Care Unit
Cardiac critical care developed out of the need to provide highly specialized care for children with complex congenital cardiac disease. The earliest pediatric cardiac surgeries were open procedures without the need for cardiopulmonary bypass, such as patent ductus arteriosus ligation (1938) and aortic coarctation repair (1945), and were performed by Robert Gross with no substantial complications. However, later surgeries became more complex and required longer periods of recovery with a wider array of complications, and thus different groups of providers were enlisted to control and restore organ function.
In 1944 Alfred Blalock and Vivien Thomas performed a left subclavian artery to left pulmonary artery anastomosis on a 1-year-old child with tetralogy of Fallot. This case was complicated by the onset of bilateral pneumothoraces during the postoperative course that required drainage and highlighted the care provided by pediatric house staff members.
In 1953 use of cardiopulmonary bypass for repair of cardiac defects by John Gibbon heralded the development of the field of congenital cardiac surgery. Subsequently surgeries became more intricate as increasingly complex defects were repaired. In 1958 William Glenn performed the superior vena cava to right pulmonary artery anastomosis on a 7-year-old patient with functionally univentricular anatomy, decreased pulmonary blood flow, and transposition of the great arteries. During surgery this case was complicated by cardiac arrest and atrial tachycardia that was later controlled with digitalis. In 1968 Francois Fontan performed the atriopulmonary connection in a 12-year-old patient with tricuspid atresia and normally related great vessels. After surgery the child developed anuria requiring hemodialysis during postoperative day 1 and later a right pleural effusion requiring drainage.
By the 1970s complex congenital cardiac surgeries were mostly performed in older children. The use of prostaglandin E to maintain ductal patency, along with advances in cardiac catheterization and echocardiography, resulted in advances in neonatal cardiac surgery. In 1974 Aldo Castaneda and the team at Boston Children’s Hospital reported their experience performing open-heart surgery during the first 3 months of life and the postoperative management of these children. These efforts, along with others, led to a revolution in neonatal congenital cardiac surgery and cardiac intensive care. In 1975 Adib Jatene performed the arterial switch operation that now bears his name. This case had substantial complications, characterized by renal failure and eventual death of the patient on postoperative day 3. Since then the arterial switch operation and the postoperative care for these patients has been optimized, and some centers report survival rates of up to 96% at 7 years.
In the late 1970s hypoplastic left heart syndrome (HLHS) was almost invariably lethal. The surgical and clinical community was challenged by the lack of a feasible surgical repair and sustainable postoperative care. In 1977 William Norwood performed surgery on a 5-week-old infant with HLHS. The procedure consisted of an atrial septal defect enlargement, a cavopulmonary connection, a ductal ligation, left pulmonary artery banding, and side-to-side anastomosis of the aorta and main pulmonary artery. This case was complicated by desaturation, progressive acidosis, and the patient’s eventual death. However, improvements in the surgical technique and postoperative care have largely improved outcomes, with some large studies reporting survival of over 75% after the stage I (Norwood) procedure.
These procedures revolutionized and expanded the treatment of congenital cardiac disease and stimulated the development of pediatric CICUs focused on improving postoperative care. This ever-expanding field includes a steep learning curve and significant challenges for trainees. The 21st-century CICU provider must have a unique set of skills, characterized by in-depth knowledge of complex cardiac physiologies and understanding of the pathophysiology of critical illness and the unique ability to lead a multidisciplinary team capable of dealing with the most complex situations a patient with critical cardiac disease may encounter.
Cardiac Intensive Care Unit Staffing and Coverage
It is difficult to precisely determine staffing in the CICU with over 100 congenital surgery programs in the United States and many more across the world. A recent international survey of members of the Pediatric Cardiac Intensive Care Society (PCICS) provided demographic information regarding unit structure, staffing, and training of cardiac intensivists. Based on this survey, the most frequent CICU staffing structure is composed of nurses and physicians independent from the general pediatric intensive care unit (PICU) (58%), followed by combined units (PICU/CICU) with dedicated CICU nurses and physicians (21%) and combined units (PICU/CICU) with no dedicated nurses and physicians (21%). In terms of staffing and training of CICU providers, the most common training background was critical care (51%), followed by cardiology (18%), dual training in critical care/cardiology (14%), and last, dual training in critical care/anesthesiology (10%).
Cardiac Intensive Care Training Pathways
Identifying the ideal education and training pathways for CICU providers is an area of active discussion. Currently most CICU providers are trained in critical care, cardiology, anesthesiology, or various combinations of the three. To understand the current training pathways, it is important to recognize the organization that oversees residency and fellowship training in the United States. The Accreditation Council for Graduate Medical Education (ACGME) is the governing body that sets the educational standards for the training of US physicians in residency and fellowship. The ACGME has instituted specific requirements for specialty and subspecialty training programs focused on ensuring the highest quality of training within these programs. The American Board of Pediatrics (ABP) is the entity that determines board certification eligibility for providers and has its own requirements that revolve around satisfactory development of clinical, professional, and academic skills. Although ABP board certification has long been established in pediatric cardiology and pediatric critical care, there currently is no certification offered in pediatric cardiac critical care.
Providers who seek board certification in pediatric critical care or cardiology must complete 3 years of training after pediatric residency. The ACGME and ABP do not have specific guidelines or requirements for CICU service duration; in fact, within pediatric critical care programs the ABP specifically limits time that can be spent in a “subspecialty ICU” to 6 months over the course of a pediatric critical care medicine (PCCM) fellow’s 3 years of training. Fellowship programs in either specialty typically will have fellows rotate 3 to 4 months during the 3-year training program. Night coverage varies among centers based on the size of the program and the number of fellows available. For instance, large programs with more than five fellows per year in either specialty may have trainees cover four to seven overnight calls during their CICU rotation months, as well as additional night coverage throughout the duration of training. Other programs might use a night float system, resulting in fellows covering the cardiac patients for five or six nights at a stretch. Smaller programs may have much less cardiac exposure, and some fellows may train at a center where either pediatric cardiology fellows and/or PCCM fellows function mostly as observers in the CICU. Clearly there is marked inconsistency in the exposure of both cardiology and critical care trainees to care of CICU patients.
Dual training is available for board-eligible or board-certified providers in pediatric critical care or cardiology. Depending on the training background, trainees on this track must complete 2 years of additional training, of which at least 1 year must be broad-based clinical training. The training background generally determines the curriculum, and it is typically defined by the individual needs of the trainee and the program’s need for service coverage. Typical rotation schedules for both a board-eligible cardiologist training in critical care and for a board-eligible intensivist training in cardiology are shown in Tables 6.1 and 6.2 , respectively. Specific rotation requirements are not set forth by the ABP; therefore significant variations are possible depending on the training program and the previous training experience of an individual fellow. It should be noted that the ABP has no specific research requirement for fellows who undertake a second pediatric subspecialty fellowship, provided that the scholarly project from the initial subspecialty fellowship was approved by the appropriate ABP subboard and that the fellow has successfully passed that subboard examination. It is in the trainee’s academic interest to continue moving forward with academic pursuits to better position himself or herself for a junior faculty position.
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Although formal recognition by the ABP of programs for dual training in anesthesia and PCCM no longer exists, the board will, on a case-by-case basis, consider individual applications for dual training in both subspecialties. Stipulations for that training are as follows :
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The pathway is available to those who have completed the required training for certification in general pediatrics.
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Both the anesthesiology and PCCM training must be completed in the same institution or in close geographic proximity in the same academic health system.
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Training in PCCM may precede or follow training in anesthesiology, or the training may be fully integrated.
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An individual in the pathway must be identified by the end of the first year of training or preferably before training begins in anesthesiology and PCCM.
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An outline of the 5-year plan that details how the training requirements of the ABP, the American Board of Anesthesiology (ABA), and the ACGME will be met must be submitted to both boards for approval. Individuals will be approved for this pathway on a case-by-case basis; programs will not be approved.
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Although double counting of scholarly activity/research experience is allowed, all clinical training requirements must be met in each discipline and may not be double counted.
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Six months of the scholarly activity required for PCCM certification will be completed during the 6 months of research time allowed during the anesthesiology residency. The trainee’s scholarship oversight committee will oversee this training, as required by the ABP’s General Criteria for Certification in the Pediatric Subspecialties.
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The 5 years of training will not confer eligibility for certification in pediatric anesthesiology by the ABA.
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Trainees in the pathway will be eligible for certification in both anesthesiology and PCCM upon the satisfactory completion of all 5 years of training. Certification in one discipline is not contingent upon certification in the other.
This wide range of training pathways and the conflicting opinions from experts in the field regarding the ideal training model led to the development of an additional year of cardiac critical care training. This training is currently available for providers who have completed a pediatric critical care, cardiology, or neonatology fellowship, though currently there is no ACGME accreditation available for this additional clinical fellowship year. The curriculum of this additional year will depend on the provider’s training background, but typically the initial months focus on the development of basic skills required in the CICU not covered during their previous training. For providers with pediatric critical care background, particular emphasis is placed on solidifying echocardiography, electrophysiology, and cardiac catheterization skills and interpretation, whereas providers with a pediatric cardiology background will focus on the stabilization and management of the critically ill child. The second part of the year will focus on the development of skills necessary to successfully lead a multidisciplinary team to provide care of a critically ill child with congenital or acquired cardiac disease throughout the child’s CICU stay.
Curriculum and Trainee Assessment
Curriculum
The multiple training pathways currently available to physicians who seek to practice in the CICU presents a challenge: how to ensure that each trainee acquires the necessary knowledge and skills to provide optimal, efficient, and safe care to this high-risk patient population regardless of the training pathway. Educators within pediatric cardiology have offered the most extensive expert analysis of what specifically should be required of trainees in their field who seek to practice in the CICU. While recognizing that core training in pediatric cardiology is not the same at all institutions and thus some modifications to postfellowship training might be required, Task Force 5 of the American College of Cardiology has twice published its recommendations regarding what constitutes an adequate fourth-year experience to prepare a board-eligible/board-certified pediatric cardiologist to practice in the CICU (see Table 6.1 ). Not surprisingly, the response from those trained in critical care, many of whom had long practiced in the CICU, was to conclude that “all critically ill children are best cared for by a multidisciplinary team of clinicians with the intensivist as a team leader or co-leader.” These authors made the following additional points with regard to the adequacy of a fourth year of clinical training to prepare a cardiologist to lead a CICU team:
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Abbreviated critical care rotations do not transform a cardiologist into an intensivist any more than a few clinical months of cardiology training would convert an intensivist into a cardiologist.
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Training for any physician who wishes to practice PCCM or any other pediatric subspecialty should not be fast tracked.
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Physicians who wish to fulfill both the cardiologist and the intensivist roles in the CICU should follow the 5-year training path outlined by the ABP for dual certification in PCCM and pediatric cardiology.
They concluded that “there should be no shortcuts in the care of critically ill children”—a point on which all who care for these high-risk patients can undoubtedly agree. The Task Force 5 authors reasonably countered that “efforts to gerrymander qualification boundaries to exclude able practitioners from practice work against, rather than foster, a culture of multidisciplinary collaborative care.”
An expert panel composed of individuals of diverse training backgrounds was convened at the 10th annual meeting of the PCICS in 2014 to discuss the merits of the contribution of their field to the care of patients in the CICU. One walks away from the opinions offered feeling quite uncertain that any single training pathway is the only right one:
From anesthesiology: The anesthesiologist is the intensivist of the operating room, and delivering care as the pediatric cardiac anesthesiologist is similar to delivering care in the CICU at two to three times the normal speed—albeit one patient at a time.
From cardiology: The practice of pediatric cardiac critical care goes beyond typical intensivist and cardiologist proficiencies. Extra time for skill acquisition in a mentored environment is advantageous. The completion of two fellowships is not necessary to function at a high level as a cardiac intensivist.
From critical care: Key elements of training are patient exposure, pattern recognition, reflection, collaboration, and humility; although working with providers of varying practice backgrounds can be frustrating, it is also an opportunity to evaluate the evidence and identify strategies that make sense.
From cardiology/critical care: These fields provide the advantage of exposure to diverse disease states and complex care of all organ systems in which communication with a wide variety of subspecialists is imperative, while also providing an advanced understanding of the complex physiology in the CICU patient population.
From neonatology: A background in neonatology adds expertise to the trainee in the preterm and very low-birth-weight population, as well as managing comorbidities specific to neonates.
Given the landscape of various training backgrounds that have lead people to practice in the CICU, it perhaps is the right time to take a step essentially backward to define the knowledge and skills that a CICU provider must have. Rather than focus on the path, developing a curriculum will allow us to focus on eliminating gaps in knowledge and abilities rather than highlighting them.
A proposed curriculum that stresses knowledge and skills is shown in Table 6.3 . It is purposefully brief because it will hopefully stimulate discussion across the multiple specialties that have sent practitioners into the field of cardiac intensive care. Although it focuses on the specific clinical skills required to independently practice as a cardiac intensivist, additional abilities in the areas of professionalism, communication, team leadership, and academic pursuits will be equally important.
| Patient care and medical knowledge: noncardiac |
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| Patient care and medical knowledge: cardiac |
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| Procedural skills |
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